Learning about your spouse’s infidelity can be emotionally and physically devastating. The emotional damage is reflected in what some mental health professionals call Post-Infidelity Stress Disorder (PISD), for the stress and emotional turmoil experienced afterward.

Psychologist Dennis Ortman, author of Transcending Post-Infidelity Stress Disorder, describes the term as “not to suggest a new diagnostic category but to suggest a parallel with post-traumatic stress disorder, which has been well documented and researched.”

In Post-Traumatic Stress Disorder (PTSD), re-experiencing the trauma repeatedly is the first of three categories of symptoms described. The disorder is marked by flashbacks of war for veterans, nightmares of the accident for car wreck survivors, and painful memories of abuse for survivors of intra-familial trauma.

So too, in PISD husbands and wives will replay the painful realization of betrayal. Even after the initial fall-out, people will have recurring thoughts of their partner with another.

Psychologist and certified sex therapist, Barry Bass, adds, “Like trauma victims, it is not unusual for betrayed spouses to replay in their minds previously assumed benign events,” those times when their spouse became defensive when asked a simple question, or the late nights at work, or the text messages from unnamed friends, all of these become viewed as possible deceitful acts.

The second category of symptoms for PTSD, avoidance and emotional numbing, is seen in PISD as well. Rage or despair that comes after the initial shock of discovering the infidelity can be followed by a state of emotional hollowness. Formerly pleasurable activities lose their appeal. Those who were cheated on sometimes withdraw from friends and family and describe feelings of emptiness.

The last category of PTSD symptoms, hyper-vigilance and insomnia, can also arise for those dealing with infidelity. Sleep patterns become erratic; and concentration becomes a challenge, affecting work performance and family life.

PISD can have physical consequences as well as emotional ones. The stress of discovering infidelity can lead to what has been dubbed broken heart syndrome, also termed stress cardiomyopathy. The American Heart Association describes symptoms such as sudden chest pain, leading to the sense that one is having a heart attack. Physical or emotional stressors, such as a loved one passing or major surgery trigger a surge of stress hormones that temporarily affect the heart. The condition typically reverses within a week.

Despite the stress, there is life after an affair. Due to the symptomatic similarities, therapists are now beginning to use PTSD counseling techniques to help couples either stay together or move on.

Exposure and cognitive restructuring are techniques used when dealing with traumatic memories. In exposure, spouses are asked to gradually imagine those heart-wrenching moments and to cope with them gradually, whereas cognitive restructuring substitutes irrational thoughts, feelings, and behaviours induced by the trauma, with adaptive ones.

Counselors use these “trauma focused” explorations with clients, sifting through the distressing memories and aversive feelings, to help build the client’s self-esteem and confidence in dealing with the betrayal or loss of the relationship.

Therapists are also working with their clients to help them understand the unique reasons that led to the infidelity. Understanding why the affair occurred can help both people.

Along with help from family and friends, wounds can be bandaged and trust restored. Infidelity trauma and the time and strength involved in recovery remind us that love, like war, can have its casualties.

Traumaticbrain injuries (TBI) contribute to many deaths each year, and can lead to the development of secondary mental health problems. The Centre for Disease Control has reported that approximately 1.7 million TBIs occur every year, and individuals with a TBI commonly suffer cognitive impairments and developmental delays.

The Trauma & Mental Health Report recently spoke with Tricia Williams, a clinical neuropsychologist at Holland Bloorview Kids Rehabilitation Hospital, who works with children who have different forms of TBI. Williams explained how to improve child development and mental health for individuals coping with a TBI.

Q: What are the most common injuries that lead to the development of a TBI?

A: A TBI is caused when an external mechanical force, such as a blow to the head or a concussive force causes harm to the head or body. Motor vehicle accidents are the leading cause of TBIs.

Other common injuries include falls (which are common in young children and infants), sport injuries, concussions, horseback riding, interpersonal violence (fighting, gun shots, physical hits to the head by person/object,) and war related injuries.

Q: How is a TBI diagnosed?

A: Professionals in emergency services diagnose a TBI in the acute state at the time of injury. They assess the severity of the injury by checking eye responses, verbal responses, motor responses, and mobile ability. CT scans are initially performed to rule out bleeding and swelling, and then an MRI may be performed as follow up. Amnesia is another way to diagnose a TBI. The degree of memory loss prior to the event, and difficulty forming new memory can provide more information about the injury. The duration of loss of consciousness can also affect the severity of the injury, which may be ranked as either mild, moderate, or severe.

Q: What is involved in rehabilitation following a TBI?

A: In the acute state, the TBI is managed medically, including neurosurgical intervention. Once stabilized at the hospital, children move on to rehabilitation. An assessment of physical, functional, and speech abilities are conducted, and occupational therapists and speech and language pathologists then work with the children. Neuropsychological assessments are conducted after the acute state to help children transition back to school. The children continue with follow-up visits to monitor the impact of the injury on developing cognitive skills.

Q: As a clinical neuropsychologist, what is your role with patients who have a TBI?

A: Children are seen as inpatients at the hospital after the injury, and are also seen as outpatients after they have transitioned home. They can be followed for many years after the injury. Typically, they are seen during transitional periods such as the transition from primary school to high school. A thorough assessment of the child’s skills (IQ, memory and learning, language, processing speed, executive functioning, academic skills, visual and motor skills, socio-emotional status) are conducted and compared to previous testing to assess the child’s progress and developing difficulties.

Q: What daily activities can become difficult for an individual with a TBI?

A: Activities that can be difficult depend on the nature and severity of the injury, the stage of recovery, and how well they have been supported. Common complaints across all injuries include: keeping up with class, forgetfulness, difficulty paying attention, and becoming easily fatigued, overwhelmed, and frustrated. Because these activities can be challenging, continued support from their physicians and neuropsychologists as well as family support is very important during the recovery process.

Q: How can secondary mental health symptoms develop from a TBI?

A: Depression is a common outcome, and can develop as a reaction to the injury or to neurochemical changes in the brain. Anxiety is also a common reaction to the injury, because if the child is old enough to understand what has happened, they might expect it to happen again. This is common for children who developed a TBI as a result of a sports injury. Children can also be anxious about their academic achievement and about performing well in school. It is important to make patients aware of potential secondary mental health symptoms. But, individuals with a TBI can also have a greater appreciation of life, as they see themselves as survivors.

Q: What advice can you offer someone with TBI?

A: Be patient with yourself and try to normalize your emotional variability. It’s important to ask for and accept help, and to find the balance between accepting what has happened and moving on. Individuals should keep in mind that while there are variable outcomes, full recovery is possible. Finding a “new normal” for oneself without becoming centered on the injury is extremely important.

Use your phone or equivalent to make dictated notes and reminders with regularly scheduled playback times

Break down (or ask someone to help you break down) larger tasks into smaller manageable parts

Choose the time of day when you are most able to accomplish tasks that require more obvious mental effort and sustained attention

Recognize the signs that you are losing attention/productivity or becoming overwhelmed and take a break

Exercise can help relieve tension, improve sleep and attention

Seek out a quiet room to complete work or practice techniques as needed

Social support is extremely helpful

Traumatic brain injuries (TBI) contribute to many deaths each year, and can lead to the development of secondary mental health problems. The Centre for Disease Controlhas reported that approximately 1.7 million TBIs occur every year, and individuals with a TBI commonly suffer cognitive impairments and developmental delays.

The Trauma & Mental Health Report recently spoke with Tricia Williams, a clinical neuropsychologist at Holland Bloorview Kids Rehabilitation Hospital, who works with children who have different forms of TBI. Williams explained how to improve child development and mental health for individuals coping with a TBI.

Q: What are the most common injuries that lead to the development of a TBI?

A: A TBI is caused when an external mechanical force, such as a blow to the head or a concussive force causes harm to the head or body. Motor vehicle accidents are the leading cause of TBIs.

Other common injuries include falls (which are common in young children and infants), sport injuries, concussions, horseback riding, interpersonal violence (fighting, gun shots, physical hits to the head by person/object), and war related injuries.

Q: How is a TBI diagnosed?

A: Professionals in emergency services diagnose a TBI in the acute state at the time of injury. They assess the severity of the injury by checking eye responses, verbal responses, motor responses, and mobile ability. CT scans are initially performed to rule out bleeding and swelling, and then an MRI may be performed as follow up. Amnesia is another way to diagnose a TBI. The degree of memory loss prior to the event, and difficulty forming new memory can provide more information about the injury. The duration of loss of consciousness can also affect the severity of the injury, which may be ranked as either mild, moderate, or severe.

Q: What is involved in rehabilitation following a TBI?

A: In the acute state, the TBI is managed medically, including neurosurgical intervention. Once stabilized at the hospital, children move on to rehabilitation. An assessment of physical, functional, and speech abilities are conducted, and occupational therapists and speech and language pathologists then work with the children. Neuropsychological assessments are conducted after the acute state to help children transition back to school. The children continue with follow-up visits to monitor the impact of the injury on developing cognitive skills.

Q: As a clinical neuropsychologist, what is your role with patients who have a TBI?

A: Children are seen as inpatients at the hospital after the injury, and are also seen as outpatients after they have transitioned home. They can be followed for many years after the injury. Typically, they are seen during transitional periods such as the transition from primary school to high school. A thorough assessment of the child’s skills (IQ, memory and learning, language, processing speed, executive functioning, academic skills, visual and motor skills, socio-emotional status) are conducted and compared to previous testing to assess the child’s progress and developing difficulties.

Q: What daily activities can become difficult for an individual with a TBI?

A: Activities that can be difficult depend on the nature and severity of the injury, the stage of recovery, and how well they have been supported. Common complaints across all injuries include: keeping up with class, forgetfulness, difficulty paying attention, and becoming easily fatigued, overwhelmed, and frustrated. Because these activities can be challenging, continued support from their physicians and neuropsychologists as well as family support is very important during the recovery process.

Q: How can secondary mental health symptoms develop from a TBI?

A: Depression is a common outcome, and can develop as a reaction to the injury or to neurochemical changes in the brain. Anxiety is also a common reaction to the injury, because if the child is old enough to understand what has happened, they might expect it to happen again. This is common for children who developed a TBI as a result of a sports injury. Children can also be anxious about their academic achievement and about performing well in school. It is important to make patients aware of potential secondary mental health symptoms. But, individuals with a TBI can also have a greater appreciation of life, as they see themselves as survivors.

Q: What advice can you offer someone with TBI?

A: Be patient with yourself and try to normalize your emotional variability. It’s important to ask for and accept help, and to find the balance between accepting what has happened and moving on. Individuals should keep in mind that while there are variable outcomes, full recovery is possible. Finding a “new normal” for oneself without becoming centered on the injury is extremely important.

Q: Do you have any further suggestions for coping with a TBI?

A: Here is a list of helpful tips:

Take additional time on activities as neededManage fatigue (with exercise/relaxation, sleep)Ask for repetition of key information and written outlines of key terminologyRepeat back what people tell you to ensure you are understandingUse your phone or equivalent to make dictated notes and reminders with regularly scheduled playback timesBreak down (or ask someone to help you break down) larger tasks into smaller manageable partsChoose the time of day when you are most able to accomplish tasks that require more obvious mental effort and sustained attentionRecognize the signs that you are losing attention/productivity or becoming overwhelmed and take a breakExercise can help relieve tension, improve sleep and attentionSeek out a quiet room to complete work or practice techniques as neededSocial support is extremely helpful

“It’s hard, but I think it must be harder for my husband, being away for so long. He missed a lot of firsts when the girls were babies. Thankfully, between deployments he got to see with one, the things he missed with the other.”

Blair Johnson, mother of two, Mackenzie age 5, and Macey age 2, has experienced firsthand the hardships of having a spouse away on deployment, as her husband Nathan, an American marine, has spent half of their marriage overseas and in training.

Deployment, the movement of troops overseas for military action, is a reality for many families in the U.S. and Canada. The American military is deployed in more than 150 countries around the world, with the majority of troops in combat zones.

Deployed soldiers often face great emotional strain as they are forced to separate from their spouses and children. The separation, distance, and heartache make parenting in these families an enormous challenge. Children, who tend to be most sensitive to changes within the family, may react strongly.

“For me, it has been harder with my older daughter during Nathan’s most recent deployment. Since she is such a Daddy’s girl, she acted out a lot in trying to deal with her father being away. She would give me a hard time, almost like she thought I could control whether or not her Dad was home.”

Amy Drummet, a researcher at the University of Missouri explains that military families experience stress at three main junctions: relocation, separation, and reunion. As Blair recalls, separations bring on feelings of parental inadequacy and guilt. “It’s the feeling that I can’t give my girls everything they need when it’s just me; they miss their Dad and I can’t do anything to bring him home.”

To complicate matters, the return home can be just as problematic. “The last time he came back was different than the previous ones. It took a lot longer for everything to return to normal. Jumping back into the role of a full-time father was harder for him.”

One in every five soldiers returning home from Iraq or Afghanistan may suffer from posttraumatic stress disorder (PTSD). This prevalence makes it difficult for the returning parent to carry on normal parenting responsibilities. “When Nathan returned, he was very jumpy, angry, and agitated with every loud sound he heard. He would constantly reach for his gun even though he didn’t even have it once he returned home. He had to learn to let go of the defense mode he was used to.”

Coming home presents many obstacles the family must overcome in order to settle back into a normal and familiar way of living. Apart from the joy of having one’s partner return home, there is plenty of work that must be done to adapt to previous family roles.

“The girls hold a lot of anger towards me after he is home and it is heart breaking; they don’t want anything to do with me for the most part. Since I am the main disciplinarian the majority of the time, they see him as the good guy. They want to spend every moment with him when he is around, because they just miss him so much when he’s gone.”

“I have been blessed to have parents with whom we can stay during his deployments. For us, it helped a bit in filling the void of Daddy being gone. We take advantage of the time we can spend together, so all the family can be a part in their lives,” says Blair.

Military children are especially vulnerable during a deployment due to separation from their parent, a perceived sense of danger, and an increased sense of uncertainty. “I asked Mackenzie what she thought Daddy was doing when he is deployed and she said, ‘he is working…and fighting the bad guys.’”

Despite the difficulties, Blair insists that there are good aspects to deployment, “You have to make a choice to either let it affect you in a bad way or a good one. You can use that time to grow closer instead of growing distant. It is all a matter of choice. I believe something good can come from any situation, no matter how terrible it is. It makes you a stronger person and it helps you realize just how much you can handle.”

Deployment drastically affects family life. While it requires all family members to readjust, children, who are more prone to being agitated by their changing circumstances, may find it harder to cope. As parents battle their own issues and uncertainties, they may unintentionally miss signs that their children need them.

So deployment may have an effect on the attachment with not only the deployed parent, but also with the parent who stays behind. The confusion and uncertainty experienced by children should be treated with love and understanding, while maintaining their normal routine.

“Parents have their bad days, but it’s important to cry, let it all out, and then move on. Happiness is an everyday choice, and choosing it doesn’t mean you miss your spouse any less.”

“I thought he must die. He had no future, nothing good. I thought I was saving the child.”

Nerlin Sarmiento had expressed disturbing thoughts about her children long before tragedy struck her small family of four. On many occasions the 32-year-old Edmonton mother had confessed to doctors and family members that she had thoughts of harming herself and her children.

Precautions were taken: Sarmiento was admitted to hospital several times, prescribed psychiatricmedication, discharged, and had her mother move in to help care for the children.

On the morning of February 12th 2013 in Edmonton, Alberta, Sarmiento sent her ten-year-old daughter to school, then forced her seven-year-old son into the bathroom where she held him under water until he stopped breathing.

Sarmiento did not deny murdering her son. She called the police herself to report the crime. Her lawyers, however, argued that she should not be held responsible on account of her mental illness that prevented her from appreciating the moral wrongfulness of her actions.

Two psychiatrists testified at Sarmiento’s trial. They explained that she was experiencing a severe depressive episode as part of her previously diagnosed bipolar disorder. She felt despair so extreme she became convinced she was committing an altruistic act, saving her son from a life of predestined poverty and hardship.

On September 12th, 2013, Justice Sterling Sanderman agreed. Nerlin Sarmiento was found not criminally responsible (NCR) on a charge of first-degree murder.

The public outcry against the ruling was reminiscent of the aftermath of the Vincent Li and Guy Turcotte trials; they were found NCR on charges of second-degree murder and first-degree murder respectively.

NCR has been a hot topic featured prominently in the press following several high profile cases, but is often misunderstood.

In Canada, if the court decides that an individual has committed a criminal act (i.e., they are guilty), but lacked the capacity to know that their actions were not only criminally wrong, but also morally wrong at the time, a verdict of not criminally responsible may be given.

Psychiatrist Robert Dickey with Correctional Service Canada and the University of Toronto helped the Trauma & Mental Health Report gain a better understanding of NCR and bust some of the myths surrounding the defense.

Myth 1: Almost anyone can claim they have a mental disorder and use the NCR defense.

Technically, this is true. But whether or not they would be successful is another story, says Dickey, explaining that if you don’t have a severe mental illness, it is very hard to malinger your way through an NCR assessment and defense.

He further explains that the finding of NCR is based on the exact mental state of the accused at the time of the crime. By the time someone is referred for assessment by the courts, their state of mind may be quite different than it was when the offense was committed.

A good clinician will seek clear corroborating information that the individual was suffering from a psychotic illness at the time they were arrested. The police, jail and institutional records should give information as to the individual’s mental state at the time.

This is not a matter of being a little depressed, states Dickey. The individual must be so ill that they would not have been able to tell right from wrong, appreciate the wrongfulness of their actions or engage in rational choice when the crime occurred.

Myth 2: The NCR defense is a tactic for offenders to skirt the justice system.

Mostly false, says Dickey. If an individual does not suffer from a psychotic illness, pure psychopathy or criminality alone is not considered – by the law – to be a disease of the mind severe enough to qualify for a finding of NCR.

If the NCR defense is successful, the individual is remanded to the custody of the Provincial Review Board, where the offender is encouraged to receive treatment. Interestingly, the board itself has no power to order the accused to engage in treatment.

But if an accused does refuse, they are often detained in a secure facility. Dickey explains that with cases of major mental illness and the refusal of treatment, the physician can refer the offender to the Consent and Capacity Review Board. And the individual may be declared incapable to refuse psychiatric treatment and treated against their will.

Myth 3: When a person is found NCR for a crime, they essentially walk free.

False. The vast majority of offenders found NCR spend a lot more time detained in a secure facility than if they had been found guilty and served a regular prison sentence, Dickey explains. Because the consequences of NCR are more restrictive and more ensuring of treatment, the issue is now more readily raised by the crown (prosecution) than the defense.

After the individual has been remanded to the Provincial Review Board, the forensic psychiatrist will testify as to the necessary level of security needed to manage the offender and their psychiatric care, while still ensuring the safety of the community.

So what’s in store for Nerlin Sarmiento?

When her trial concluded, she was remanded to the custody of the Alberta Review Board (ARB). At a hearing within 45 days from the end of her trial, the ARB determined whether she would receive an absolute discharge, a conditional discharge or be detained in custody. The results of Sarmiento’s hearing have yet to be made public.

Red, and your heart starts to race. Red, and your palms sweat. Red, and the sounds around you blur together. Imagine becoming emotionally aroused or distressed at the sight of simple stimuli, like the colour red, without knowing why.

Because triggers like this can take the form of harmless, everyday stimuli, trauma survivors are often unaware of them and the distress they cause in their lives. And clinicians who practice without the benefit of a trauma-informed lens are less able to help clients make the connection.

To address this and other concerns, researchers Nancy Poole and Lorraine Greaves in conjunction with the Centre for Addiction and Mental Health (CAMH) in Toronto recently published Becoming Trauma Informed, a book focused on the need for service providers working in the substance abuse and mental health fields to practice using a trauma informed lens.

Becoming Trauma Informed provides insight into the experiences, effects, and complexity of treating individuals who have a history of trauma. Without a clear understanding of the effect traumatic experiences have on development, it is challenging for practitioners to make important connections in diagnosis and treatment.

The authors describe how someone who self-harms may be diagnosed with bipolar disorder, possibly insufficiently treated with only medication and behaviour management. But using a trauma informed lens, the practitioner would more likely identify the self-harming patient as using a coping mechanism common to trauma survivors, giving rise to trauma informed care.

Such care involves helping survivors recognize their emotions as reactions to trauma. And helping clients discover the connection between their traumatic experiences and their emotional reactions can reduce feelings of distress.

Throughout the text, the authors describe an array of treatment options, pointing to ways they can be put into practice; for example, motivational interviewing to provide guidance during sensitive conversations, cognitive behavioural therapy for trauma and psychosis, and body centred interventions to allow clients to make connections between the mind and body, an approach that has become increasingly popular in recent years.

Importantly, the authors emphasize that a single approach to trauma-informed care is unrealistic and insufficient. While all treatments should include sensitivity, compassion, and a trusting relationship between therapist and client, specific groups require unique approaches.

The authors devote chapters to specific groups, including men, women, parents and children involved with child welfare, those with developmental disabilities, and refugees. They outline different approaches necessary for trauma informed care in various contexts, such as when working in outpatient treatment settings, in the treatment of families, and when working with women on inpatient units, where treatment requires sensitivity to both the individual’s lived experiences and environment.

A unique and compelling feature of this book is the focus on reducing risk of re-traumatization, an often neglected topic. Responding to the need for trauma survivors to feel safe, the authors outline how trauma informed care minimizes the use of restraints and seclusion (practices that can be re-traumatizing), and they offer ways to reduce the risk of re-traumatization by placing trauma survivors in less threatening situations, where they are less likely to feel dominated. This may involve matching female clients to female therapists or support groups comprised of only females.

The numerous case studies help illustrate specific scenarios, challenges, and outcomes of trauma informed care and highlight the growing recognition of the link between substance abuse, mental illness and traumatic experiences.

While the text is theoretically grounded, the authors convey information in a way that is accessible to wider audiences. It provides critical information for those working in the field by underscoring the relationship between past experiences and current functioning.

Becoming Trauma Informed delivers a deeply informative look into the field of trauma therapy.

“Fifteen years ago there were very few people who knew about FASD. If you were to go to court and say, ‘My son or daughter has FASD,’ a judge wouldn’t even know if it was a real thing.” – Jonathan Rudin, Justice Committee Co-Chair at the FASD Ontario Network of Expertise

Recently referred to as an “invisible condition” by the popular Canadian newspaper, The Globe And Mail, Fetal Alcohol Syndrome Disorder (FASD) often goes undiagnosed.

A supervisor at the Toronto Children’s Aid Society described to the Trauma & Mental Health Report the stream of FASD cases that have recently found their way into youth care and justice systems.

“You often don’t know a child has FASD because the mother is not around to confirm alcohol exposure during pregnancy. With one case, we suspected it, and did some digging. The grandparents of the child confirmed that the mother did consume alcohol during pregnancy. It was the grandparent’s report that changed everything. Nobody would have known.”

Characterized by growth deficiencies and central nervous system damage, FASD is an incurable condition. According to Ernest Abel, Professor of Obstetrics and Gynaecology at Wayne State University and Ronald Sokol, Professor of Paediatrics at the University of Colorado, FASD is the leading cause of mental retardation.

The Canadian Academy of Child and Adolescent Psychiatry explains that mothers often feel intense guilt and are typically blamed for damage to the child. For this reason, they are not always forthright about drinking habits. Stigma also plays a powerful role in motivating mothers to withhold information. And often, mothers consumed alcohol before they knew they were pregnant and are therefore unable to recall precise quantities and timing of drinks.

Adelaide Muswagon, a single mom, was featured in the Winnipeg Free Press in an article on FASD. “It took a lot of courage for me to get help. I know behind my back I was called an alcoholic and druggie. I can’t change what I have done; I already harmed my child. But I want expecting mothers to know my story, realize the consequences, and not make the same mistakes I did.”

The diagnosis of FASD is only given at birth for the most extreme cases. More often than not, symptoms are mild and fall within the normal range of development. For a firm diagnosis, confirmation of alcohol use during pregnancy is required. Because FASD can look like other medical, psychosocial and psychiatric conditions, children can be mistakenly labelled with Attention Deficit Hyperactivity Disorder (ADHD) or a behavioural disorder.

Fortunately, the behavioural symptoms associated with FASD are becoming better known. As we learn more about the hardships associated with the condition, mothers may question their decision to be vague or dishonest about drinking.

Liz Kulp, award winning author, advocate, and person living with FASD speaks candidly about her experiences in her book, The Best I Can Be: Living with Fetal Alcohol Syndrome-Effects.

“Finding out [why life was so hard for me] didn’t change how hard life is, but it did make me believe I was not a bad person. When I ask a question, it is because I don’t understand, not because I have not been listening, sometimes there is a blank space and I can’t get across it. I may look really normal and I work really hard to maintain. That is really stressful and sometimes I get frustrated. Sometimes the stress just builds up, especially when different people put different expectations on me all at the same time.”

For students, FASD manifests with attention problems and difficulties understanding instructions and rules. Common sense can be lacking, along with a tendency to take things literally. Learning issues lead to high drop-out rates. Youth with FASD often become involved in criminal justice systems, and many such individuals are overrepresented in prison populations. Jonathan Rudin, an Ontario lawyer and chair of the FASD Justice Committee says people with FASD are “usually not the mastermind behind the crime” but they are “easily convinced to take the rap.”

Catching the condition early in life and understanding its effects can help with education, parenting strategies, and legal provisions.

Moving through life without knowing why things are harder for you and why everyone else seems to be able to function with ease can be devastating. Sadly, people with undiagnosed FASD often grow up using alcohol to cope, possibly giving birth to a child with FASD.

Alleviating stigma around FASD by providing mothers with a non-judgemental space to speak about their drinking may help with diagnosis and treatment.

“If we are to teach real peace in this world, and if we are to carry on a real war against war, we shall have to begin with the children” – Mahatma Gandhi

Over 18 million children are currently living in regions affected by war. While most humanitarian aid groups focus on meeting the basic physical needs of these children, in the midst of armed conflict, cognitive, social and emotional development is often inhibited and overshadowed by regional chaos.

Exposed to violent, traumatic and stressful situations that threaten their sense of stability and well-being, children have few places to simply be children, where they can play, learn and socialize safely. And few resources are in place to help them heal from the psychological burdens of war.

As the need for rehabilitative and restorative measures gains greater recognition by the international community, a growing number of child rights advocates, organizations and researchers are stepping forward to understand the implementation of psychologically therapeutic programs for war-affected children. The challenge is in figuring out what is needed, what is available and what will work across a variety of cultures, contexts and settings.

Seeking to bring psychological care on a tight budget, academics and policy advisors have emphasized evidence-based programs. Theresa Betancourt, professor and director of the research program on children and global adversity at Harvard’s school of public health, and her colleagues are evaluating the effectiveness of child trauma programs based in countries such as Uganda, Sierra Leone, Chechnya, Gaza, Sudan, Kosovo, Bosnia and Croatia.

Individual therapeutic interventions such as trauma focused therapy and narrative exposure therapy have shown promise among children affected by war and are approved by UNICEF as preferred techniques.

Group interventions have been used to accommodate the psycho-social needs of a greater number of children. These include Interpersonal group therapy for depression, creative play, mother-child psycho-education and support, and torture group psychotherapy with cognitive behavioural techniques.

Some other psycho-social initiatives have focused on the creation of Child Friendly Spaces (CFS’s) and Temporary Learning Centers (TLC’s) within refugee camp settings or local communities. These provide a child-centered environment for play, basic education and socialization; and they identify children in psychological distress.

But some concerns have been noted. The focus on trauma can lead to community stigmatization. In addition, these therapies are hard to carry out on a large scale due to the high costs of employing highly-trained professionals. Individualized services are rare and reserved for severely distressed children, usually demobilized child soldiers.

Problems arise when trying to apply western definitions and measures of distress that are not necessarily applicable to other cultures and contexts. And in understanding any given child’s psychological functioning, it is important to factor in ongoing stressful events and the social dynamics that a war-affected child must deal with on a daily basis.

There has been a movement away from a traditional western “clinical treatment” model toward a more inclusive, holistic framework of “psycho-social intervention,” termed to reflect the complex interplay between a child’s psychological and social development.

More effective group interventions for children have tended to be those that involve a school setting, address everyday stressors, utilize a form of trauma/grief-focused psychotherapy or use mind-body relaxation and coping techniques such as meditation, biofeedback and guided imagery.

Still, universal, comprehensive, culturally-sensitive psychological services for war-affected children remain a long way off. For more information on mobile psycho-social and education programs for war-affected children, please check out The Freedom to Thrive Foundation. Email FreedomToThriveFoundation@gmail.com to find out how you can get involved.

Some of the most common questions posed to parents of newborns, particularly by other parents, relate to sleeping patterns. Choices around sleep can be personal and sometimes controversial.

In western cultures, it is normal to put infants in different rooms. But in much of the rest of the world, the baby either sleeps with parents (bed-sharing) or in close proximity to the parent (co-sleeping).

These differing traditions often present a dilemma to parents in western societies who hear opposing points of view when seeking advice.

James McKenna, professor of anthropology at the University of Notre Dame considers that despite the dominant view (no bed-sharing), parents increasingly are opting for co-sleeping or bed-sharing. In fact, half of U.S. parents with infants bed-share with their children during at least part of the night.

This is especially true for breastfeeding mothers as co-sleeping can make night-time feeding easier to manage. It is thought by many that co-sleeping while breastfeeding results in the mother being more in-tune with the infant’s immediate hunger needs and as a result, the infant quickly learns that their needs can be satisfied. This contributes to the development of secure attachment.

According to the American Academy of Pediatrics and Academy of Breastfeeding Medicine, mothers should sleep in close proximity to their baby not only to help facilitate breastfeeding but also to improve the survival rate of the developing infant.

McKenna also indicates that from an anthropological viewpoint the proximity and sensory touch associated with bed-sharing induces positive behavioural and physiological changes in the infant. Studies have found long-term benefits of bed-sharing or co-sleeping. For example, children who bed-shared were found to have less anxiety and a higher level of comfort in social situations later on.

Traditional western medical views on bed-sharing tend to be rather negative. Based on the Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada, the main reason cited is the threat of sudden infant death syndrome (SIDS).

The Joint statement defines SIDS as, “the sudden death of an infant less than one year of age, which remains unexplained after a thorough case investigation, including the performance of a complete autopsy, an examination of the death scene, and a review of the clinical history.”

Because it is difficult to distinguish specific causes of death that occurred during sleep, in many SIDS cases the cause may be cited as “unintentional suffocation due to overlaying,” which may be used to discourage bed-sharing.

Yet in many of the studies where infant deaths are discussed, parental smoking, alcohol consumption and unsafe sleeping practices are often major factors, as opposed to bed-sharing per se. Understanding preventative measures and safe sleeping practices can help reduce the incidence of SIDS.

Further, some research has found a strong link between breastfeeding and lowered risk of SIDS. Fern Hauck of the University of Virginia reviewed 18 studies that looked at the relationship between these two variables and found that babies exclusively breastfed had a 70% lower risk of SIDS, and the risk is lowered further the longer breastfeeding continues. Researchers attribute this lowered risk to infants being able to awaken more easily, reducing the risk of sudden death.

Daniel Flanders, pediatrician at North York General Hospital in Toronto, states that as a physician he follows the guidelines for the prevention of SIDS, but feels that strong recommendations against bed-sharing undermine parental choice on how to raise one’s child. He notes that in non-westernized communities bed-sharing is often a major part of the cultural practice of child rearing, and therefore his approach is to present the most relevant and up-to-date information available so the parent can make an informed decision.

There are several measures one can take to reduce the risks associated with bed-sharing. One of the most important things for the baby’s safe sleep is ensuring that the surface the infant sleeps on is firm, smooth and flat. Sheets should be tucked and never loose, whether the child sleeps with the parents, in a sidecar or in the crib.

If parents choose to bed-share there should be ample space for all, with both parents agreeing to the arrangement. The bed should not be shared with multiple children, especially if one or more are slightly older. Also, if the bed is raised off the floor there should be a mesh guardrail around the bed to prevent the baby from falling over. If the bed is against the wall, parents should ensure that there is no gap between the bed and the wall at all times.

Although bed-sharing is often discouraged by many in the medical community due to its association with an increased risk of SIDS, this does not mean that the practice is without benefit. Done safely, bed-sharing and co-sleeping offer unique opportunities for the development of closeness between parent and child.

Parents must choose the arrangement that works best for them and their families. For more information: Safe Sleeping Practices for Infants

We have heard countless stories speaking to the injustices and brutalities faced by women in Afghanistan. In Letters to My Daughters, Fawzia Koofi, an Afghan woman writes about her personal experiences living in Afghanistan during the civil war.

A member of parliament in Afghanistan, Koofi, 35, is chairperson of the standing committee on human rights and civil society, and a candidate for the presidential elections in 2014.

Her book is a memoir, beginning from birth when her mother left her to die from exposure. The first half focuses on Koofi’s struggles with her limited access to education. She explains that she was the only girl from her family who was allowed to attend school, and only because her father was no longer present. Once the Taliban took control, she was immediately forced to quit medical school.

In a later section of her book, Koofi describes a trip she took to northern Afghanistan with a team of foreign surveyors. There she realized that one of the biggest difficulties faced by women was access to health care services -a problem that did not exist before the war. Once the civil war began many facilities were destroyed, and most physicians were forced to migrate to neighboring regions.

The situation was further exacerbated when the Taliban took over. Women were no longer allowed to work in health care facilities, except in a select few hospitals (functioning under deplorable conditions) designated for women only. Male doctors were prohibited from seeing female patients and female doctors were seldom allowed to work, leaving female patients without treatment.

Many women living in smaller cities and villages still do not have access to health care services, leaving them to die from illnesses as common and easily treatable as diarrhea.

Throughout the book, Koofi describes how she consistently experienced inhumane treatment by Afghan men. Systematic genderdiscrimination was made worse with the arrival of the Taliban and, although they have been removed from power, the prejudice still continues in most regions to this day.

Women are still harassed if they leave the house without their shroud-like burqas and a male chaperone. Many women around the world face domestic violence. As is often the case, the abuse occurring in Afghanistan is considered a family matter, without much hope of intervention or help from authorities.

Koofi emphasizes that the arrival of the American forces resulted in liberation of Afghan women. Critics accuse her of being a “traitor” for siding with the Americans, and some consider Koofi to have obtained personal gain by writing a book that humiliates the Taliban and elevates the status of the U.S.

Although Letters to my Daughters describes Koofi’s personal experiences, the memoir sheds light on the troubling hardships many Afghan women face. Although change seems more likely with a new democratic government in place, it will still take years before the women of Afghanistan are able to enjoy the opportunities that Koofi and other women are fighting for.

The book provides a fascinating insight into her personal struggle, and the struggle of so many like her. Koofi’s book is a must read for anyone interested in understanding Afghan women’s traumatic experiences.